Ensuring Data Integrity and Protecting Your Organization’s Bottom Line: Part IV

Part IV in this series discusses expanding HIM’s visibility and enhancing organizational processes via authorization denial management.

In my prior article, I discussed the value of payer policy management, and mentioned that “no authorization” denials represent 10-15 percent of all denials. This focused denial category presents another opportunity for health information management (HIM) professionals. HIM can monitor such denials in a process improvement role. 

Many organizations perceive denials management as a back-of-the-house process, but all authorizations are a front-of-the house responsibility. For physician practices, denials for lack of authorization represent 80 percent of the total, so working with your hospital-employed providers to avoid such pitfalls by capturing the authorizations required at the time of scheduling the service will mean “cha–ching” – and you know that’s what your CFO wants to hear.

So, what do we need to do?

First: Build off of the work done by the payer policy manager (see my article titled Expanding HIM’s Visibility and Enhancing Organizational Processes: Payer Policy Management). Once we have cataloged the various payers’ requirements, we’ll know which services need prior authorizations. Tie each of those to its designated CPT code.

Second: Access or registration needs to check eligibility for each patient, and when that’s done, checking whether an authorization is required for any planned services should be part of the registration (or, at a minimum, pre-registration) workflow. There are robotics-assisted applications and services available that can assist access in checking both eligibility and securing an authorization. Approximately 23 percent of those responding to a recent survey by Change Healthcare indicated that determining if an authorization was required was the most challenging task they faced. Again, this points to the value of payer policy management.

Third: Remember that building the authorization checking into the workflow may also mean understanding the patient care process, and robots may be deficient in this respect. Don’t stop at getting an authorization only for scheduled services. Obtaining authorizations for anticipated services is just as vital. For example, a surgeon may plan to do a biopsy, but depending on the results, he or she may decide to do a more invasive procedure that also requires an authorization. If that service is done during the same encounter – bang. Denial! 

Sitting in access at the hospital should be someone with some clinical expertise, such as a coding professional, who knows that this is a normal chain of events. In the physician office, the authorization specialist can quiz the physician to ensure that authorizations are captured for the commonly anticipated services.

Some inpatient procedures require authorizations as well. Since eligibility may change during a given stay, the workflow for scheduling should include re-checking eligibility throughout the stay, and also obtaining authorizations for any new procedures planned.

Fourth: Teach physicians to document reasons for services likely to be denied, such as screening procedures ordered earlier than the payer’s guidelines recommend due to the patient’s family history; this is an example of something the physician needs to document to support the medical necessity for the procedures. This documentation should be provided when requesting an authorization. Again, this is a documentation improvement education opportunity for a coding professional who serves as an authorization specialist for high-cost tests or procedures.

Fifth: Design edits in the test scheduling and claims billing processes to flag that a CPT code entered requires an authorization. The edit should check to see if there is an authorization number in the designated claim’s field (CMS 1500, field 23; UB04, field 63, etc.). When the field is blank, the scheduler, registrar, or biller should be alerted. Case management may need to be involved to secure authorizations after the fact. 

Sixth: Track the denials that arise due to no authorization. Track by payer, CPT®, and physician so that you can update payer policies, build edits for the CPTs, and provide education to providers and their staff in order to avoid denials proactively.

According to an Healthcare Financial Management Association (HFMA) article, up to 65 percent of denied claims are never appealed. Focusing attention on denials for lack of authorization and reducing those denials through process improvement will reduce the labor costs to research and appeal denials, as well as increase revenues – and that’s what we’re going for.

Good luck!

Programming Note: Listen to Rose Dunn report this story live today during Talk Ten Tuesdays, 10 Eastern.

Facebook
Twitter
LinkedIn

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Sepsis: Bridging the Clinical Documentation and Coding Gap to Reduce Denials

Sepsis: Bridging the Clinical Documentation and Coding Gap to Reduce Denials

Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.

September 24, 2025
2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025

Trending News

Featured Webcasts

E/M Services Under Intensive Federal Scrutiny: Navigating Split/Shared, Incident-to & Critical Care Compliance in 2025-2026

E/M Services Under Intensive Federal Scrutiny: Navigating Split/Shared, Incident-to & Critical Care Compliance in 2025-2026

During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.

August 26, 2025
The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24